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Optimum Gold Rewards Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Optimum Gold Rewards Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Optimum Gold Rewards Plan (HMO) in 2026, please refer to our full plan details page.
Optimum Gold Rewards Plan (HMO) is a HMO plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Select Counties in Florida. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Optimum Gold Rewards Plan (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Optimum Gold Rewards Plan (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Optimum Gold Rewards Plan (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4200.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Optimum Gold Rewards Plan (HMO) offers prescription drug coverage with a $0 drug deductible, meaning your benefits begin immediately. For Tier 1 preferred generic drugs, there is no copay for one, two, or three-month supplies at preferred pharmacies, standard pharmacies, and standard mail order. Tier 2 preferred brand drugs require a copay of $10 for a one-month supply at both preferred and standard pharmacies, as well as through standard mail order. Tier 3 non-preferred drugs have a $70 copay for a one-month supply at preferred pharmacies and standard mail order, and a $75 copay at standard pharmacies. For Tier 4 specialty drugs, you will pay a 33% coinsurance for a one-month supply across all retail pharmacy and standard mail order options.
Additional Benefits
The Optimum Gold Rewards Plan (HMO) offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, while specialist visits require a $35 copay. Inpatient hospital stays cost $195 per day for the first seven days, followed by no copay for days eight through 90. Outpatient hospital services carry a $195 copay, and emergency room visits require a $150 copay, which is waived if you are admitted. This plan also includes valuable supplemental benefits, such as routine dental, vision, and hearing exams with no copay or coinsurance, alongside a $50 monthly over-the-counter item allowance. Prescription hearing aids are covered up to $500 per ear, and eyeglasses or contact lenses require just a $10 copay up to a $100 limit. For recovery needs, skilled nursing facility care has no copay for the first 20 days, and home health services are fully covered with no copay or coinsurance.
Inpatient Hospital See details
Optimum Gold Rewards Plan (HMO) covers inpatient acute and psychiatric hospital care with no coinsurance and a copay of $195 per day for days 1 through 7, followed by no copay for days 8 through 90. This benefit is partially covered, as additional days, upgrades, and non-Medicare-covered stays are not covered, and prior authorization and referrals are required.
Outpatient Services See details
Optimum Gold Rewards Plan (HMO) covers outpatient services with no coinsurance, featuring a $195 copay for outpatient hospital and observation services, a $25 copay for ambulatory surgical center visits, and a $35 to $195 copay for outpatient substance abuse sessions. Outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Optimum Gold Rewards Plan (HMO) covers partial hospitalization services with a $50 copay and no coinsurance. Prior authorization and a referral are required for this benefit.
Ambulance and Transportation Services See details
Optimum Gold Rewards Plan (HMO) covers ground ambulance services with a $200 copay and air ambulance services with a 20% coinsurance. Transportation services are partially covered with no copay or coinsurance for up to 6 one-way trips per year to plan-approved locations, but trips to any health-related location are not covered.
Emergency Services See details
Optimum Gold Rewards Plan (HMO) covers emergency services with a $150 copay, which is waived if admitted to the hospital within 72 hours, and no coinsurance. Urgently needed services require a $20 copay with no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $100,000 maximum with a $500 copay per service and no coinsurance.
Primary Care See details
Optimum Gold Rewards Plan (HMO) features primary care physician visits with no copay and no coinsurance, while specialist visits, physical therapy, and mental health services require a $35 copay and no coinsurance. Chiropractic and podiatry services are not covered, but other covered services like telehealth and opioid treatment are available with no coinsurance and copays ranging up to $195.
Preventive Services See details
Preventive Services are partially covered by the Optimum Gold Rewards Plan (HMO) with no copays and no coinsurance for all covered care, although referrals and prior authorizations may be required. Covered benefits include Medicare-covered zero-dollar preventive care, kidney disease education, memory fitness, and remote access technologies, while annual physical exams, health education, and personal emergency response systems are not covered.
Hearing Services See details
Hearing services are partially covered by the Optimum Gold Rewards Plan (HMO), offering no copays and no coinsurance for annual routine exams, fitting evaluations, and prescription hearing aids with a $500 maximum benefit per ear. OTC hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered under this plan.
Vision Services See details
Optimum Gold Rewards Plan (HMO) offers partially covered vision services with no deductible and no coinsurance, including one annual routine eye exam with no copay, while other eye exams are not covered. Covered eyewear has a $10 copay for one annual pair of contact lenses or eyeglasses (lenses and frames) up to a $100 maximum limit, but separate eyeglass lenses and frames are not covered.
Dental Services See details
Optimum Gold Rewards Plan (HMO) provides dental services with no copay and no coinsurance for covered treatments such as exams, cleanings, x-rays, fluoride, restorative care, periodontics, and oral surgery. This benefit is partially covered, as other diagnostic, other preventive, endodontics, prosthodontics, implants, adjunctive general, and orthodontic services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered under the Optimum Gold Rewards Plan (HMO) with no copay, though prior authorization is required. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis services are covered by the Optimum Gold Rewards Plan (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical Equipment is covered by the Optimum Gold Rewards Plan (HMO) with no copay, though prior authorization is required for all services. Members will pay a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic shoes, while diabetic supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the Optimum Gold Rewards Plan (HMO), requiring referrals and prior authorization. Lab services and outpatient X-rays feature no copay, diagnostic procedures have a copay ranging from $0 to $195, and diagnostic radiological services have a minimum $25 copay, with 20% coinsurance applying to therapeutic radiology and diagnostic tests.
Home Health Services See details
Home health services are covered under the Optimum Gold Rewards Plan (HMO) with no copay and no coinsurance. Both prior authorization and a referral are required to receive this care.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered with no copay and no coinsurance under the Optimum Gold Rewards Plan (HMO), though in practice some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) services are covered by the Optimum Gold Rewards Plan (HMO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization and referrals are required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Optimum Gold Rewards Plan (HMO) partially covers other services, with acupuncture, dual eligible SNPs, and other unspecified services not covered. Covered benefits include over-the-counter items up to $50 monthly and chronic illness meal benefits, both of which feature no copay and no coinsurance.
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